Assessment of Left Ventricular Systolic Function Using Color-Coded Tissue Doppler Echocardiography

Tissue Doppler echocardiography can be used to measure myocardial velocity data by using the Doppler shift data of ultrasound waves. Two methods have recently been described to calculate velocity data: pulsed tissue Doppler and color-coded tissue Doppler. This article focuses on color-coded tissue Doppler data to evaluate left ventricular systolic function. Technical considerations and validation studies are reviewed. Potential clinical applications of color-coded tissue Doppler are presented, including dobutamine stress echocardiography, assessment of left ventricular ejection dynamics using mitral annular velocity, and tissue Doppler assessment of cardiac transplant rejection.     

超声心动图评价左心室功能的研究进展

左室功能的准确测定对临床诊断和治疗有着重要意义,超声心动图是目前最常用于测量左室功能的工具,其具有无创、廉价、重复性好等优点,更为重要的是它不仅可用于评价左室整体收缩功能,还能更加完善地评价左室舒张功能和局部心肌运动,现对近年来超声心动图评价上述心功能的主要方法进行回顾。     

多普勒组织显像技术评价左室舒张功能的研究进展

左室舒张功能障碍在心血管疾病中很常见,二尖瓣血流频谱是评价左室舒张功能障碍的经典方法,但存在不足。多普勒组织显像技术是一项应用多普勒原理分析心肌组织运动的新技术,包括心肌速度显像、定量组织速度显像、组织追踪以及应变/应变率,这些方法为评价左室舒张功能提供更多、更有益的信息。     

Quantitative Tissue Doppler Echocardiography: Physiological Nonuniformity of Left Ventricular Transmural Myocardial Wall-Motion Velocities and Gradients

Tissue Doppler echocardiography (TDE) is a new method by which transmural myocardial function can be studied noninvasively. In order to investigate physiology and reproducibility, 24 young, healthy volunteers were examined by M-mode TDE. Nonuniformity of transmural tissue layer velocities became apparent: Subendocardial and subepicardial velocities of the anteroseptal myocardial wall (AW) were 3.5 ± 0.7 and 1.3 ± 0.5 cm/sec (P < 0.0001 , t- test), whereas in the posterolateral wall (PW) values of 3.6 ± 0.6 and 1.2 ± 0.4 cm/sec (P < 0.0001 , t- test ), respectively, were revealed. The ratios, termed "myocardial velocity gradients" as a new indicator of left ventricular performance, were 3.1 ± 1.0 and 3.4 ± 1.1, respectively. AW and PW did not differ (N.S.). Tolerance borders did not overlap, and intraobserver variability did not reach intersubject variability (P < 0.0001, F-ratio test). TDE provides new and more sophisticated insights into left ventricular performance. It seems to be accurate and reliable and therefore worth introducing into the clinical arena.     

彩色M型多普勒超声评价高血压病人的左室舒张功能

目的 应用彩色M型多普勒超声心动图测量舒张早期左室内血流传播速度(vp)，评价高血压病人的左室舒张功能。方法 高血压组195例(50岁以下者23例；50—70岁者101例；70岁以上者71例)。正常对照组136例(如岁以下者53例；50—70岁者50例；70岁以上者33例)。取心尖四腔或二腔心平面测量左室内血流传播速度(Vp)，二尖瓣和肺静脉血流曲线。结果 高血压病人的Vp值较正常人降低(P＜0．01)，血流形态异常。结论 应用彩色M型多普勒超声心动图测量舒张早期左室内血流传播速度，不受心脏负荷及年龄的影响，作为评价高血压病人左室舒张功能的指标有临床意义。     

Tissue Doppler to Assess Diastolic Left Ventricular Function

Doppler indices of left ventricular (LV) filling have been used traditionally for the assessment of LV diastolic function. In many circumstances, however, the interpretation of these indices is difficult because they respond to alterations of different physiological variables such as preload, relaxation, and heart rate. A typical example of their limitation is seen in patients with abnormal LV relaxation and increased preload compensation, who often present a "pseudonormal" LV filling pattern. Thus, there is a need for noninvasive indices of diastolic function capable of discriminating the effects of relaxation and preload. Tissue Doppler echocardiography (TDE) is available in most modern cardiac ultrasound imaging systems. TDE can be used to obtain regional myocardial velocities during isovolumic relaxation, early filling, and atrial systole with high spatial and temporal resolution. This article discusses the complementary role, limitations, and future challenges of TDE in the study of diastolic function.     

Assessment of Left Ventricular Function and Tei Index by Tissue Doppler Imaging in Patients with Slow Coronary Flow

Background: The aim of this study was to assess left ventricular (LV) function and the Tei index by tissue Doppler imaging (TDI), and also to evaluate the relationship of thrombolysis in myocardial infarction (TIMI) frame count (TFC) with the Tei index and LV function in patients with slow coronary flow (SCF). Methods: We prospectively evaluated 50 patients with SCF and 27 control subjects. Diagnosis of SCF was made by TFC. LV systolic and diastolic function was assessed by conventional echocardiography and TDI. Results: Early diastolic mitral annular velocity (Em), Em/Am, and peak systolic mitral annular velocity (Sm) were lower in patients with SCF than those in controls (13±2.8 cm/sec vs 15.2±2.8 cm/sec, P = 0.002; 0.88±0.22 vs 1±0.23, P = 0.03; and 14.1±3.51 vs 16.5±3.31, P = 0.005, respectively). In patients with SCF, the Tei index was significantly higher than that in controls (0.34±9.6 vs 0.29±9.5, P = 0.02, respectively). Mean TFC and RCA TFC were positively correlated with the Tei index (r = 0.3, P = 0.02 and r = 0.329, P = 0.02). Left circumflex (LCX) TFC was negatively correlated with Em/Am (r =–0.310, P = 0.03) only in patients with SCF. Conclusion: LV systolic and diastolic function is impaired in patients with SCF. TDI analysis of mitral annular velocities such as the Tei index, Em, Em/Am, and Sm is useful to assess LV systolic and diastolic dysfunction in patients with SCF. Mean TFC and RCA TFC were positively correlated with the Tei index and LCX TFC was negatively correlated with Em/Am. TDI may be better than conventional echocardiography in assessing LV function in patients with SCF. (ECHOCARDIOGRAPHY, Volume 26, November 2009)     

The Evaluation of Left Ventricular Functions with Tissue Doppler Echocardiography in Adults with Celiac Disease

Background/Aim:

The aim of this study was to investigate the effects of celiac disease on cardiac functions using tissue Doppler echocardiography (TDE).

Patients and Methods:

The study included 30 patients with celiac disease (CD) and 30 healthy volunteers. Echocardiographic examinations were assessed by conventional echocardiography and tissue Doppler imaging. The peak systolic velocity (S^''m), early diastolic myocardial peak velocity (E^''m), late diastolic myocardial peak velocity (A^''m), E^''m/A^''m ratio, myocardial precontraction time (PCT^''m), myocardial contraction time (CT^''m), and myocardial isovolumetric relaxation time (IVRT^''m), E to E^''m ratio were measured.

Results:

In pulsed wave Doppler echocardiography, mitral late diastolic flow (A) velocity and E to E^''m ratio were significantly higher (P = 0.02 and P = 0,017), E/A ratio was significantly lower (P = 0.008) and IVRT was significantly prolonged (P = 0.014) in patients with CD. In TDE, S^''m, E^''m, and E^''m/A^''m ratio were significantly lower, IVRT^''m was longer (P = 0.009) from septal mitral annulus and S^''m, E^''m, E^''m/A^''m ratio were significantly lower, PCT^''m, PCT/ET ratio, IVRT^''m were longer, and MPI was higher from lateral mitral annulus in celiac group than controls.

Conclusion:

Our study confirms that patients with CD have impaired diastolic function. More importantly, we also demonstrated an impairment of myocardial systolic function in patients with CD by TDE. We recommend using TDE in addition to conventional echocardiography parameters for the cardiovascular risk assessment of patients with CD.     

Reference Values of Tissue Doppler Imaging and Pulsed Doppler Echocardiography for Analysis of Left Ventricular Diastolic Function in Healthy Adults

To determine reference values for tissue Doppler imaging (TDI) and pulsed Doppler echocardiography for left ventricular diastolic function analysis in a healthy Brazilian adult population. Observations were based on a randomly selected healthy population from the city of Vitória, Espírito Santo, Brazil. Healthy volunteers (n = 275, 61.7% women) without prior histories of cardiovascular disease underwent transthoracic echocardiography. We analyzed 175 individuals by TDI and evaluated mitral annulus E′‐ and A′‐waves from the septum (S) and lateral wall (L) to calculate E′/A′ ratios. Using pulsed Doppler echocardiography, we further analyzed the mitral E‐ and A‐waves, E/A ratios, isovolumetric relaxation times (IRTs), and deceleration times (DTs) of 275 individuals. Pulsed Doppler mitral inflow mean values for men were as follows: E‐wave: 71 ± 16 cm/sec, A‐wave: 68 ± 15 cm/sec, IRT: 74.8 ± 9.2 ms, DT: 206 ± 32.3 ms, E/A ratio: 1.1 ± 0.3. Pulsed Doppler mitral inflow mean values for women were as follows: E‐wave: 76 ± 17, A‐wave: 69 ± 14 cm/sec, IRT: 71.2 ± 10.5 ms, DT: 197 ± 33.3 ms, E/A ratio: 1.1 ± 0.3. IRT and DT values were higher in men than in women (P = 0.04 and P = 0.007, respectively). TDI values in men were as follows: E′S: 11± 3 cm/sec, A′S: 13 ± 2 cm/sec, E′S/A′S: 0.89 ± 0.2, E′L: 14 ± 3 cm/sec, A′L: 14 ± 2 cm/sec, E′L/A′L: 1.1± 0.4. E‐wave/ E′S ratio: 6.9 ± 2.2; E‐wave / E′L ratio: 4.9 ± 1.7. In this study, we determined pulsed Doppler and TDI derived parameters for left ventricular diastolic function in a large sample of healthy Brazilian adults. (Echocardiography 2010;27:777‐782)     

Tissue Doppler Echocardiography: Future Developments

The use of color-coded tissue Doppler echocardiography has resulted in rapid technological advances in the evaluation of cardiac function. This article describes some of these exciting new advances, including curved M-mode analysis and strain rate imaging. Data from studies in animals and humans are presented to demonstrate the potential clinical use of this new echocardiographic diagnostic tool.     

Tissue Doppler Combined with Pulsed‐Wave Doppler Echocardiography for Evaluating Ventricular Diastolic Function in Normal Children

Background: The ratio of the peak transmitral velocity during early diastole (E) to the peak mitral valve annular velocity during early diastole (E′) obtained by tissue Doppler imaging correlates with the left ventricular end‐diastolic pressure in adults. However, the E/E′ ratio has not been established in normal children. The purpose of this study was to assess the effect of age on the various tissue Doppler indices of ventricular diastolic function. Methods: The subjects in this study included 174 children with normal cardiac function. The left and right ventricular inflow velocities were recorded, and the peak of late diastolic flow velocities (A), E, and the ratio of E/A were determined. The following tissue Doppler indices were obtained: peak velocities of early and late diastolic mitral annulus in the left ventricular lateral wall (E’l and A’l) and in the interventricular septum (E’se and A’se) and those of the lateral tricuspid annulus in the right ventricle, E’r and A’r. Results: The E’l and the E’se increased with age up to 5 years after birth, after which they became constant. The E’r was constant after birth. The E’l/A’l and E’se/A’se increased with age up to 5 years after birth, after which they became constant. The E’r/A’r was constant after birth. The Em/E’se and Em/E’l decreased with age up to 5 years after birth, after which they became constant. The Et/E’r was constant after birth. Conclusion: The age‐related changes suggest age‐related alterations in left ventricular diastolic function. Right ventricular diastolic function is constant after birth. (Echocardiography 2011;28:93‐96)     

Clinical Value of the Tissue Doppler S Wave to Characterize Left Ventricular Hypertrophy as Defined by Echocardiography

Left ventricular hypertrophy (LVH) may be a physiological finding and may also be associated with different disease entities and hence, with different outcomes. Regional myocardial function can be assessed with color Doppler tissue imaging, specifically by the waveform of the isovolumic contraction (IC) period and the regional systolic wave (“s”). Methods and Results: We studied five groups (G): healthy, sedentary young volunteers (G1, n:10); healthy sedentary adult volunteers (G2, n:8); and subjects with LVH (left ventricular mass index >125 g/m²) including: high performance athletes (G3, n:21), subjects with hypertension (G4, n:21), subjects with hypertrophic cardiomyopathy (HCM) (G5, n:18). We measured peak “s” wave velocity (cm/sec) at the basal and mid septum, the IC/s ratio, and basal to mid‐septal velocity difference (BMVD) of the “s” wave. Regional “s” wave values (cm/sec) were G1 = 5.6 ± 1; G2 = 5.4 ± 0.8; G3 = 5.7 ± 0.6; G4 = 5.3 ± 1.1; G5 = 4.2 ± 1.1 (P < 0.0001). The IC/s ratio was G1 = 0.28 ± 0.18; G2 = 0.39 ± 0.21; G3 = 0.23 ± 0.10; G4 = 0.42 ± 0.15; G5 = 0.64 ± 0.15 (P < 0.0001). The BMVD (cm/sec) was G1 = 2 ± 0.51; G2 = 1.71 ± 0.29; G3 = 1.78 ± 0.44; G4 = 1.26 ± 0.96; G5 = 0.45 ± 0.4 (P < 0.0001). IC/s < 0.38 discriminated physiological from pathological forms of hypertrophy (sensitivity 90%; specificity 88%). Peak “s” wave velocity discriminated HCM from other causes of hypertrophy, with a cutoff value of 4.46 cm/sec (sensitivity 72%; specificity 90%). BMVD <0.98 cm/sec detected HCM with 89% sensitivity and 86% specificity. Conclusions: Peak “s” wave velocity and two indices: IC/s and BMDV are novel parameters that may allow to discriminate physiological from pathological forms of hypertrophy as well as different subtypes of hypertrophy. (ECHOCARDIOGRAPHY 2010;27:370‐377)     

Left Ventricular Diastolic Function in Idiopathic Cardiomyopathy: Doppler Hemodynamic Correlations

The left ventricular diastolic filling pattern in congestive cardiomyopathy is heterogeneous and may vary from a "rapid filling predominant pattern" to an "atrial filling predominant pattern." The observed pattern of diastolic filling may depend on a complex interaction of factors including: left ventricular relaxation, left ventricular stiffness, external constraining forces, loading conditions, and heart rate. These factors appear to express themselves individually and collectively through alterations in the time course and extent of the transmitral pressure gradient. In this review, the physiological basis for each of these diastolic filling patterns is discussed based on previous clinical and experimental studies that either directly or indirectly address these issues. (ECHOCARDIOGRAPHY, Volume 8, March 1991)     

Comparison of Tissue Doppler Dynamics with Doppler Flow in Evaluating Left Atrial Appendage Function by Transesophageal Echocardiography in Prehypertensive and Hypertensive Patients

Increased blood pressure (BP) is associated with an increase in cardiovascular mortality and morbidity. We aimed to analyze the effect of increased BP onto the function of left atrial appendage (LAA) in early stages of hypertension. Transesophageal echocardiography (TEE) was prospectively performed to assess LAA functions in 120 patients with increased BP, and in 58 normotensive subjects without cardiovascular disease. Patients with increased BP were divided according to Joint National Committee VII (JNC VII) report: prehypertensive,stage‐1 hypertensive and stage‐2 hypertensive patients. During TEE, LAA late‐emptying velocities (LAAEV) were significantly reduced only in stage‐2 hypertensives as compared with control group (P < 0.001). In contrast, LAA late‐contracting velocity (LAA TDI‐D2) was significantly reduced in prehypertensive,stage‐1 hypertensive and stage‐2 hypertensive patients, when compared with control group (P < 0.05, P < 0.001, and P < 0.001, respectively). The LAA maximal areas were increased significantly only in stage‐2 hypertensive patients when compared with control group (P < 0.05). During TEE, left atrial spontaneous echocardiographic contrast was found in 2 of 36 patients in prehypertension group, in 7 of 40 patients in stage‐1 hypertension group, and in 10 of 44 patients in stage‐2 hypertension group. Left atrial thrombi were observed in 3 (6.8%) patients of stage‐2 hypertension group. In conclusion, in patients with untreated prehypertension and hypertension, elevation of afterload imposed on left atrium involved both left atrium and LAA, resulting in impairment of the LAA function. Tissue Doppler imaging (TDI) enables the detection of this functional impairment in early stages of hypertension, even in prehypertensive phase, when compared with conventional Doppler flow measurement of the LAA. Even in prehypertensive phase, BP should be decreased to normal levels to prevent the LAA dysfunction. (Echocardiography 2010;27:677‐686)     

Systolic and Diastolic Ventricular Function Assessed by Tissue Doppler Imaging in Children with Chronic Kidney Disease

Chronic kidney disease (CKD) is associated with elevated cardiovascular risk even during childhood. Tissue Doppler is a sensitive technique for the assessment of ventricular dysfunction with relatively little data available in children with CKD. We report a prospective cross‐sectional echocardiographic study at a tertiary center. Forty‐nine patients with median (range) age 11.2 years (6.9–17.9), weight 39.6 kg (23.6–99.7) and height 146 cm (122–185). Thirty‐one patients were male. Median duration of follow‐up for CKD was 7.1 years (range 0.13–16.9). Patients were in CKD stage 3 (n = 37) or 4 (n = 12). Mitral valve E‐wave, A‐wave, and E/A ratio showed mean (SD) z‐scores of 0.08 (0.93), 0.12 (0.82) and ?0.13 (0.84), respectively. Tissue Doppler imaging (TDI) at the lateral mitral valve annulus showed e′, a′, s′, and E/e′ z‐scores mean (SD) ?1.10 (0.76), ?0.29 (0.92), ?1.2 (0.7), and 0.86 (1.1), respectively. There was a significant negative correlation of e′ and s′ z‐score with patient age. E/e′ ratio correlated positively with patient age. Blood pressure, left ventricular mass, and relative wall thickness did not correlate with tissue Doppler measurements. The e′ and s′ velocities correlated significantly with each other, suggesting an interaction of systolic and diastolic dysfunction. Children with CKD may have abnormalities of systolic and diastolic ventricular function on TDI, which are not evident on blood pool Doppler. The tissue Doppler results are consistent with worsening ventricular function in older patients.     

Altered Early Left Ventricular Diastolic Wall Velocities in Pulmonary Hypertension: A Tissue Doppler Study

Background: Left ventricular diastolic dysfunction (LVDD) is known to occur in severe chronic pulmonary hypertension (PH); however, the mechanism(s) remains unclear. Methods: Tissue Doppler imaging (TDI) was used to track early (E) diastolic signals of basal and mid portions of the interventricular septum (IS) and LV free wall (LVFw) in 20 patients (60 ± 8 years) with documented LVDD without PH and in 30 patients (60 ± 11 years) with known chronic PH. All subjects were in normal sinus rhythm and had normal LV ejection fraction. Results: PH patients had lower early (E) wave velocities in basal IS (–4.2 ± 1.9 vs. –5.9 ± 1.2 cm/sec; P < 0.001), distal IS (–2.6 ± 2.6 vs. –4.2 ± 1.1 cm/sec; P < 0.01), and basal LVFw (–5.2 ± 1.7 vs. –6.5 ± 1.2 cm/sec; P < 0.01) than patients with LVDD and no PH. Finally, worsening PH distorts the entire IS diastolic tracing resulting in asynchronous diastolic signals. Conclusions: The presence of PH not only decreases IS early (E) wave diastolic velocity generation but also distorts the entire pattern of IS diastolic relaxation when compared to patients with typical LVDD and no PH. Further studies are now needed to assess the full effect of PH on LV diastole and how this influences clinical outcomes. (ECHOCARDIOGRAPHY, Volume 26, November 2009)